<?php


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<table class="span-24 last">
<thead>
	<tr>
		<th>Nro.</th>
		<th>Síntomas</th>
		<th>Raramente o nunca</th>
		<th>Algunas veces</th>
		<th>Frecuentemente</th>
		<th>Muy Frecuentemente</th>
	</tr>
</thead>
<tr>
	<td>1</td>
	<td>Acidez o ardor en el estómago.</td>
	<td style="text-align: center;"><? echo $form->input('ese.1', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.1', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.1', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.1', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td class="altrow">2</td>
	<td class="altrow">Pérdida del apetito.</td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.2', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.2', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.2', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.2', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td>3</td>
	<td>Deseos de vomitar o vómitos.</td>
	<td style="text-align: center;"><? echo $form->input('ese.3', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.3', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.3', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.3', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td class="altrow">4</td>
	<td class="altrow">Dolores abdominales.</td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.4', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.4', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.4', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.4', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td>5</td>
	<td>Diarreas u orinar frecuentemente.</td>
	<td style="text-align: center;"><? echo $form->input('ese.5', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.5', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.5', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.5', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td class="altrow">6</td>
	<td class="altrow">Dificultades para quedarse dormido o despertarse durante la noche.</td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.6', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.6', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.6', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.6', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td>7</td>
	<td>Pesadillas.</td>
	<td style="text-align: center;"><? echo $form->input('ese.7', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.7', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.7', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.7', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td class="altrow">8</td>
	<td class="altrow">Dolores de cabeza.</td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.8', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.8', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.8', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.8', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td>9</td>
	<td>Disminución del deseo sexual.</td>
	<td style="text-align: center;"><? echo $form->input('ese.9', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.9', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.9', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.9', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td class="altrow">10</td>
	<td class="altrow">Mareos.</td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.10', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.10', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.10', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.10', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td>11</td>
	<td>Palpitaciones o latidos irregulares del corazón.</td>
	<td style="text-align: center;"><? echo $form->input('ese.11', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.11', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.11', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.11', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td class="altrow">12</td>
	<td class="altrow">Temblor o sudoración en las manos.</td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.12', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.12', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.12', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.12', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td>13</td>
	<td>Sudoración excesiva sin haber realizado esfuerzo físico.</td>
	<td style="text-align: center;"><? echo $form->input('ese.13', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.13', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.13', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.13', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td class="altrow">14</td>
	<td class="altrow">Falta de aire sin haber realizado esfuerzo físico.</td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.14', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.14', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.14', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.14', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td>15</td>
	<td>Falta de energía o depresión.</td>
	<td style="text-align: center;"><? echo $form->input('ese.15', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.15', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.15', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.15', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td class="altrow">16</td>
	<td class="altrow">Fatiga o debilidad.</td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.16', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.16', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.16', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.16', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td>17</td>
	<td>Nerviosismo o ansiedad.</td>
	<td style="text-align: center;"><? echo $form->input('ese.17', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.17', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.17', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td style="text-align: center;"><? echo $form->input('ese.17', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

<tr>
	<td class="altrow">18</td>
	<td class="altrow">Irritabilidad o enfurecimientos.</td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.18', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(0=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.18', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(1=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.18', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(2=>''))) ?></td>
	<td class="altrow" style="text-align: center;"><? echo $form->input('ese.18', array('legend'=>false, 'label'=>false, 'type'=>'radio', 'options'=>array(3=>''))) ?></td>
</tr>

</table>